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Surgical Interventions (Acute Phase)


There is level 3 evidence (based on 1 case control: Kiwerski 1986) that cervical decompression results in improved neurological functioning in comparison to conservative treatment. This is supported by level 4 evidence (based on 1 case series: Benzel & Larson 1987) showing neurological improvement but without a control group.

There is level 4 evidence (based on 1 case series: Benzel & Larson 1986a) that thoracolumbar decompression results in improved neurological functioning among individuals with incomplete SCI but not complete SCI.

There is level 4 evidence (based on 1 case series: Hu et al. 1993) that there is no difference in neurological improvement after thoracolumbar decompression by either an anterior or posterior approach.

There is level 4 evidence (based on 1 pre-post study: Beisse et al. 2005) that endoscopic thoracolumbar surgery results in improved neurologic outcomes for both motor complete and incomplete SCI, although those with incomplete injuries have greater rates of improvement.

There is level 4 evidence (based on 1 case series: Rahimi-Movaghar et al. 2006) that decompression of lumbar burst injuries with associated conus injuries results in neurological improvement and recovery of adjacent nerve root.

There is level 3 evidence (based on several case control studies) that surgery within 24 hours of injury leads to improved neurological outcomes, shorter length of stay, and fewer complications, but not a reduction in mortality after acute, traumatic SCI.

There is level 3 evidence (based on one case control: Aito et al. 2007a) that surgical treatment of traumatic central cord syndrome does not confer neurologic benefit compared to conservative management.

There is conflicting level 2 and 4 evidence (based on one cohort: Jug et al. 2015, and five case series studies: Chen et al. 2009a; Guest et al. 2015b; Kepler et al. 2015; Liu et al. 2017; Bohl et al. 2015b) that early decompression of central cord lesions have similar neurologic outcomes to late surgery but that the latter may have lower mortality, possibly due to age-and-comorbidity-related factors.

There is conflicting level 4 evidence (based on three case series: Bucci et al. 1988; Capen et al. 1985; Rimoldi et al. 1992) on the effectiveness of surgical and non-surgical mechanical stabilization methods post SCI; methods described in the literature are quite dated and no longer used clinically.

There is conflicting level 2, 3, and 4 evidence (based on several mixed studies) that a number of prognostic factors are important in the neurological outcomes after surgery for SCI which may include, but are not limited by, prior neurological and general medical status, mean arterial pressure, spinal co-morbidities, age, complications (e.g., pneumonia, urinary track infections), walking ability, level and completeness of injury, and timing of surgery.

There is level 3 evidence (based on one cohort study: Tator et al. 1987) that surgical treatment results in lower mortality but equivalent neurological outcome compared to nonsurgical treatment; this analysis is from an early surgical era (1970s) and should be interpreted with significant caution.

There is level 1b evidence (based on one randomized controlled trial: Chhabra et al. 2016, and one pre-post study: Akbary & Arora 2014) that autologous bone marrow transfer is not effective in promoting neurological or functional recovery in individuals with traumatic SCI. Given the heterogeneity in individual status, lesion characteristics and variations in surgical experience it is likely futile to argue for the superiority of a certain approach for decompression or stabilization for compression by metastatic lesions. Instead, the surgical technique should be individualized to achieve the objectives safely.

There is level 1b evidence (from several studies) that radiotherapy and steroids, with or without surgery, improves pain from symptomatic metastatic spine compression. Additionally, for individuals younger than 65 years, the addition of surgical decompression to radiotherapy and steroids improves ambulation and survival.

There is level 2 evidence (based on one prospective controlled trial: Ghogawala et al. 2011) that anterior decompression for cervical spondylosis myelopathy may have better neurological recovery, but is also associated with higher complication rates, when compared to posterior decompression. There is no difference in disease-specific disability or quality of life between these two groups.

There is level 3 evidence (based on one case control: Liu et al. 2009, one pre-post: Kong et al. 2015, and one case series: Liu et al. 2012) that many different reconstructive options for anterior decompression have been established; however, they are not discernible in terms of quality of life or clinical outcomes.

There is level 2 evidence (from one studies included in a systematic review: Karpova et al. 2013) that radiological features such as spinal cord transverse area, and absence of spinal cord hyperintensity of MRI, both correlate with improved clinical outcome after decompressive surgery for degenerative compressive myelopathy.

There is level 2 evidence (from four prospective studies in a systematic review: Wilson et al. 2013a)) that progression from asymptomatic to symptomatic cervical cord compression is low. However, presence of concomitant radiculopathy, or electrophysiological evidence of cord dysfunction puts individuals at a higher risk of such progression.

There is level 3 evidence (one cohort study: Cao et al. 2018a) that decompressive surgery for thoracic spinal cord compression can improve quality of life and Frankel score at 1 year.

There is level 3 evidence (from one prospective cohort: Falci et al. 2009) that cord detethering with or without syrinx decompression can arrest neurological decline in individuals with delayed progressive myelopathy following SCI.

There is level 4 evidence (from studies from one systematic review: Bonn et al. 2010) that prophylactic measures for cord tethering and/or syrinx should not be taken, other than what is required to achieve primary spinal realignment / stabilization during the index surgery.

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